HDS Medicine Release Form

New form to be completed daily unless authorized by the office. We cannot administer any medications without the form.

Complete form, printing clearly and in INK.

MEDICATIONS MUST BE PRE-MEASURED!!!!!

Child’s Name: ________________________ DOB: _________   Date:______________

Child’s Teacher: ________________________

Name of Medication: __________________________________ Dosage: ___________ Is this a prescription?  Yes ______ No ______   Refrigerate? Yes____ No____

Instructions:

_____________________________________________________________________________

If your child is sleeping, do you want us to wake them to give medicine? Yes _____ No ____

Time medication was last given outside of Day School: ________

Times administered during Day School hours:

____ AM PM Teacher administering medication: ___________________________ 

          Date:_________    Witness: ___________________________________________  

____ AM PM Teacher administering medication: ___________________________ 

         Date:_________      Witness: ___________________________________________ 

____ AM PM Teacher administering medication: ___________________________ 

          Date:_________    Witness: ___________________________________________  

____ AM PM Teacher administering medication: ___________________________ 

          Date:_________    Witness: ___________________________________________  

____ AM PM Teacher administering medication: ___________________________ 

          Date:_________    Witness: ___________________________________________  

Original- home daily.  Copy- student’s office file. 

HDS emergency Medical release form

Asthma Inhaler, Epi Pen, Other

Waiting on updated form from Bari